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Moral distress in nursing is an emotional state that arises when policies or facility procedures prevent a nurse from doing what they believe to be right. When nurses feel that they should perform an ethical action but are prevented from doing so, they can feel powerless, helpless, anxious, and even depressed. All these emotions fall under moral distress in nursing.

Moral distress can not only induce anxiety but also produce physical symptoms, including:

  • Nightmares
  • Insomnia
  • Headaches
  • Gastrointestinal issues

Why is moral distress so common in nursing? It is only natural that, when nurses spend a lot of time with patients and residents, they experience both their joy as well as their suffering and stress. In short, they are invested in them emotionally. As a result, nurses in long term care are often faced with four common ethical dilemmas that contribute to their moral distress:

  1. Informed consent: These are concerns that a resident or their family are not fully informed about the treatments or administered medications. This can initially be an area of concern for nurses, as the resident may ask the nurse to decipher what a doctor says, but it then becomes an ethical issue about how much they should convey.
  2. Disclosure of medical conditions: Telling the truth vs. being deceptive to a patient or resident is another ethical dilemma that nurses face. This becomes a problem, especially when a resident has been diagnosed with a terminal illness, and their family requests that the resident not be told.  According to NurseChoice, nurses facing this ethical dilemma need to consider the resident’s right to know, as they have an obligation to the resident
  3. Incompetence among peers: Sometimes, a nurse may notice incompetent behavior from one of their team members. They may, however, be hesitant to report it, as it would worsen the nursing home’s staffing problem should the nurse be fired. These dilemmas can be framed as competing obligations—protecting the resident vs. protecting the staff—and resolving them requires creative thinking. In such a situation, there is the option of talking to the individual, assessing their level of competence and awareness, and encouraging further training, practice, or education
  4. Broader ethical issues: This includes creating and maintaining an ethical work environment and moral resilience

So how can nurses deal with such distress? What guidelines should they use? Because they have to make quick decisions, their primary resource will be the American Nurses Association’s Code of Ethics for Nurses. According to the Missouri Department of Health Care & Senior Services, the Code of Ethics serves the following purposes:

  • It states the ethical obligations and duties of every person entering the nursing profession
  • It provides the non-negotiable ethical standards of the nursing profession
  • It serves to express nursing’s understanding of its role and commitment to society

All nursing professionals are bound by their duty to protect human health as stated in the Code of Ethics for Nurses. Therefore, nurses must take a strong position on ethical issues and abide by their health care code.

By what about gray areas, matters in which the Code of Ethics is silent? According to one expert, to a certain extent, nurses need to listen to their guts. “Stick to your internal morals and values and let them guide you,” said Erica Knepper, director of business development at Holgate Center. She recently joined the LTC Heroes podcast to give her advice to nurses struggling with moral questions. “A nurse should never let others take them down a path they don’t believe in,” she said. You can listen to the entire interview below: 

Deontology in Nursing

Deontology is a theory—a theory in ethics as a whole—that suggests that, based on a clear set of rules, one can judge an action as being either good or bad. The National Library of Medicine notes that deontology is ethics of duty, where the morality of an action depends on the nature of the action. If we were to apply deontology in nursing, this would mean, harm is unacceptable regardless of its consequences. 

A nurse-resident relationship is, by its nature, deontological, as nurse training and ethics do not allow for wilful harm of patients or residents. Doing so would be considered medical negligence or malpractice. This tradition of ethics serves the purpose of getting nurses to treat residents with respect, thus strengthening the nurse-resident bond.

In contrast to the deontological approach, the utilitarian approach is one in which outcomes and the greatest benefit for the largest number of people determine the means. For a utilitarian, the end justifies the means for the greater good. Basically, in nursing, deontology is patient-centered, whereas utilitarianism is society-centered.

Why is deontology in nursing essential? The NCBI gives an example to demonstrate the clinical significance of deontology:

Consider a research study involving children who have not met the legal age of consent. Typically, the researchers would ask for the parents’ or guardians’ consent before asking the child for their permission if they are old enough to understand some details of the research. An ethical dilemma arises when the parent gives their consent, but the child does not. 

Should the researcher include the child in the research, even if the child does not want to participate? If the utilitarian ethical framework previously discussed is used, then the child would be included, even if they don’t want to participate in the research. The feelings of the child would be ignored, all for the “greater good.” However, if we apply deontological ethical theory, the researchers would persuade the children before including them. If the persuasion fails, then scientists would not include the children in the research.

The above moral dilemma demonstrates the significance of deontology in nursing; nurses must consider the thoughts and feelings of residents and consult them before making medical decisions that may affect them.

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Nursing Values

Nursing values are essential to the nursing practice, as they serve as the standard for what is expected from nurses, guide nurses’ actions, and influence nursing practices and decisions. Onward Healthcare notes five nursing values that can help nurses in  caring for residents:

Moral distress in nursing often means forgetting nursing values.
Nursing values cannot be overlooked in long term care.

a)    Compassion: This deals with empathy, care, and dignity that nurses have towards residents in their care.

b)    Trustworthiness: Residents are under the care of nurses, hence why trustworthiness is one of the most important values for nurses to have.

c)    Humility: Humility goes hand-in-hand with compassion in nursing. Nursing is a very rewarding and fulfilling career path, and humility is one of the values needed for career success.

d)    Accountability: Nurses must take responsibility for all their actions and practices. This means owning up to any mistakes, errors, or lapse of judgment and learning from them.

e)    Curiosity: Nurses should never stop learning. Curiosity and the insatiable desire to learn are what separate mediocre nurses from great ones.

7 Steps for Dealing with Moral Distress in Nursing

Nursing homes that implement the above nursing values are better equipped for dealing with moral distress in nursing. The next question worth asking is how to deal with moral distress in nursing. According to AMN Health, there are seven steps in addressing moral distress that nurses and nursing homes should take:

1.   Support the Nursing Code of Ethics

The American Nurses Association’s Code of Ethics for Nurses provides a clear framework that nurses can follow. Nurses should know the code by heart and implement it as they care for residents. As for long term care facilities, they should incorporate the Code of Ethics for Nurses into company culture as part of the vision or mission statements as well as the training for new nurses joining the facility.

2.   Offer Ongoing Education

studying
Deontology in nursing is not an easy subject, so nurses must keep up.

Like any other discipline, ethics must be learned, as ethics are not intuitive and are more than just the pursuit of “being a good person.” Therefore, employee orientation should convey the ethics and ethical behavior expected of nurses in a given skilled nursing facility. Also, examples on how to apply theoretical ethical concepts would help increase understanding. Brown University notes that when ethical decision-making is practiced regularly, the process becomes familiar, and nurses learn to work through it automatically.

3.   Make It Easy for Nurses to Speak Up

Nursing homes that create an environment where nurses can ask ethical questions or speak up about any observed ethical violations can better deal with moral distress in nursing; when nurses are in an environment where their thoughts and concerns are heard and addressed, they tend to be less morally distressed and provide better care for their residents.

Knepper notes that not speaking up in her early years as a leader was a mistake that she hopes others won’t repeat. “One of the biggest mistakes that I made is not speaking up.” she said. “I should have spoken up and advocated for my staff when I felt something was wrong. I think others should speak up and not be afraid to voice their opinions.”

4.   Bring Different Disciplines Together

Physicians also experience the pain and suffering of residents in long term care. By bringing together physicians and nurses, they can share their experiences and work together, all of which can help address moral distress. Additionally, physicians can hold joint meetings with nurses to discuss resident goals and care plans. All this fosters communication and makes it easier to address ethical issues.

5.   Consult Ethics Experts

happy folder
Moral distress in nursing can be avoided by consulting experts.

Ethics is a technical subject that is not always understood. An on-site ethical expert can help address any ethical issues and concerns that nurses or other long term care professionals may have. The National Library of Medicine notes that one of the ways of dealing with ethical challenges is through the development of clinical ethics support (CES), or, the formal or informal provision of advice and support to healthcare professionals on ethical issues.

6.   Find Ethics Mentors

Nurses who are faced with ethical issues can usually benefit from a mentor who has faced a similar dilemma. Long term care facilities can assign mentors from internal staff. They can then help the less-experienced nurses when they have concerns or ethical challenges.

7.   Reach Out to Professional Associations

Skilled nursing facilities and other long term care providers can reach out to professional associations to assist them with ethical issues. AACN has developed resources to assist nurses facing moral distress. Additionally, the American Nurses Association has a course on Everyday Ethics that can guide practicing nurses.

As for how to prevent moral distress in nursing, Oncology Nursing News lists the following tips that nurses can immediately implement in their workplace:

  • Provide quality care to their residents while remembering that it is their obligation to the community as a whole
  • Voice any concerns they may have
  • Collaborate with other professionals in other disciplines
  • Nurses should be kind to themselves—nurses should practice self-care and give themselves time to de-stress

The Importance of Managing Moral Distress in Nursing

Moral distress in nursing can result in poor patient care, diminished job satisfaction, burnout, and high turnover rates. Naturally, nursing homes and residents will suffer if nurses quit and the quality of care in the facility declines. Therefore, it is in the interest of long term care facilities to manage the moral distress their nurses may face.

Managing moral distress in nursing requires nurses and facility administrators to understand the causes of moral distress (incompetent peers, medical disclosure issues, moral resilience), the symptoms (anxiety, insomnia, headaches), and the solutions (providing education, reaching out to ethical experts).

For more on recent trends in long term care, read our blog and subscribe to the LTC Heroes podcast